AIR TRANSPORTATION SAFETY INVESTIGATION REPORT A19Q0128 LOSS OF CONTROL AND COLLISION WITH TERRAIN Beechcraft Bonanza V35B, N3804X Senneterre, Quebec, 7 NM NE 29 July 2019 II | TRANSPORTATION SAFETY BOARD OF CANADA ABOUT THIS INVESTIGATION REPORT This report is the result of an investigation into a class 3 occurrence. For more information, see the Policy on Occurrence Classification at www.tsb.gc.ca The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. 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Transportation Safety Board of Canada 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741; 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 20 20 Air transportation safety investigation report A19Q0128 Cat. No. TU3-10/19-0128E-PDF ISBN: 978-0-660-36837-5 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. AIR TRANSPORTATION SAFETY INVESTIGATION REPORT A19Q0128 | III Table of contents 1.0 Factual information............................................................................................ 2 1.1 History of the flight ...................................................................................................................... 2 1.2 Injuries to persons ........................................................................................................................ 4 1.3 Damage to aircraft........................................................................................................................ 4 1.4 Other damage ............................................................................................................................... 4 1.5 Personnel information ................................................................................................................. 4 1.6 Aircraft information ...................................................................................................................... 5 1.6.1 General ............................................................................................................................. 5 1.6.2 Range and endurance................................................................................................... 5 1.6.3 Aircraft equipment......................................................................................................... 6 1.6.4 Beechcraft Bonanza spiral dive characteristics ........................................................ 7 1.7 Meteorological information........................................................................................................ 7 1.7.1 General ............................................................................................................................. 7 1.7.2 Weather near the accident site ................................................................................... 8 1.8 Aids to navigation......................................................................................................................... 9 1.8.1 Automatic dependent surveillance – broadcast .................................................... 10 1.8.2 Aireon Aircraft Locating and Emergency Response Tracking............................. 11 1.8.3 Aireon and NAV CANADA automatic dependent surveillance – broadcast data ................................................................................................................................. 12 1.9 Communications ......................................................................................................................... 13 1.10 Aerodrome information............................................................................................................. 13 1.11 Flight recorders ........................................................................................................................... 13 1.12 Wreckage and impact information ......................................................................................... 13 1.13 Medical and pathological information ................................................................................... 13 1.14 Fire ................................................................................................................................................. 13 1.15 Survival aspects ........................................................................................................................... 14 1.15.1 Emergency locator transmitters................................................................................ 14 1.15.2 Search and rescue........................................................................................................ 14 1.16 Tests and research ...................................................................................................................... 17 1.16.1 TSB laboratory reports ................................................................................................ 17 1.17 Organizational and management information ..................................................................... 17 1.18 Additional information .............................................................................................................. 17 1.18.1 Visual flight rules flight into instrument meteorological conditions ................ 17 1.18.2 Spatial disorientation .................................................................................................. 17 1.18.3 Situation awareness..................................................................................................... 19 1.18.4 Pilot decision making.................................................................................................. 19 1.18.5 Plan continuation bias ................................................................................................ 19 1.18.6 Hypoxia .......................................................................................................................... 20 1.19 Useful or effective investigation techniques ......................................................................... 20 2.0 Analysis ............................................................................................................ 21 2.1 Plan continuation bias affecting situation awareness and pilot decision making ........ 21 2.2 Visual flight rules flight into instrument meteorological conditions ............................... 21 IV | TRANSPORTATION SAFETY BOARD OF CANADA 2.3 Spatial disorientation ................................................................................................................. 22 2.4 Search and rescue....................................................................................................................... 22 3.0 Findings............................................................................................................ 23 3.1 Findings as to causes and contributing factors .................................................................... 23 3.2 Findings as to risk ....................................................................................................................... 23 4.0 Safety action .................................................................................................... 24 4.1 Safety action taken ..................................................................................................................... 24 4.1.1 Joint